Westport Animal Shelter AdvocatesWasa Adoption Application

Date

Applying For

Name of Animal

Species

Description

Age

Special Needs

Applicant's Information

Full Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Email*

Age

Household Information

Where Do You Live?

(Please indicate one)

Neighborhood

Urban
Suburban
Rural

How long at your present address?

Do You Own Your Own Home?

Yes
No

If yes, please provide proof of ownership

Do you rent?

Yes
No

Landlord's Name

Landlord's Phone Number

Are you planning to move within the next year?

Yes
No

If yes, what are your plans for your companion animal when you move?

If you decide to move in the future, what will you do with your companion animal?

What provisions have you made for your companion animal in the event of your illness or death?

How many adults in your home?

What are their ages?

Are there children in your home? YesNo

Yes
No

If yes, how many and what are their ages?

Are all members of your household aware of your plans to adopt an animal? YesNo

Yes
No

Are any members of your household allergic to animals?

Yes
No

Where will your companion animal sleep?

How many hours will your companion animal be alone?

Who will be responsible for the animal?

Does anyone in your household smoke? YesNo

Yes
No

If yes, where?

Do you have any health conditions which could restrict your ability to care for an animal?

Yes
No

If yes, please describe

Vacation

How often do you go on vacation?

Who will care for your companion animal when you go on vacation?

Employment

Employer

Occupation

How long at your present job?

Can you be contacted at your job?

Yes
No

If yes, work phone #

Other Animals

Do you have cats?

Yes
No

If yes, How Many?

Do the cats live strictly indoors?

Yes
No

Are the cats declawed?

Yes
No

Do you have dogs?

Yes
No

If yes, How many?

Do dogs live indoors?

Yes
No

Other animals?

Yes
No

If yes, How many?

Describe living conditions of other animals

Are all animals in your household spayed/neutered?

Yes
No

Name of Veterinarian

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

If no companion animals at this time, have you had any in the past 8 years?

Yes
No

If yes, what happened to them?

References

Please list people other than family who you have known for at least 5 years.

Name

First Last

Phone Number

Name

First Last

Phone Number

Name

First Last

Phone Number

Questions

Why do you want to adopt an animal?

What type of personality are you looking for?

(If applicable) Have you ever had a special needs animal before?

Yes
No

If yes, describe

If necessary, how will you discipline the animal?

I hereby certify that all information supplied by me on this application is true.

Signature

Date

Wasa Adoption Application

WASA ADOPTION APPLICATION

Applying For

Applicant's Information

Household Information

Vacation

Employment

Other Animals

References

Questions